A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?
"Do you feel you need treatment?"
"Who is the governor of this state?"
"What do you get when you subtract 7 from 100?"
"How do you get money for your needs?"
The Correct Answer is A
A. "Do you feel you need treatment?"
Asking the client, "Do you feel you need treatment?" assesses their insight into their own mental health condition. Insight refers to the client's awareness and understanding of their illness, including recognizing the need for treatment. A positive response to this question indicates the client's awareness of their condition and willingness to seek help, demonstrating good insight.
B. "Who is the governor of this state?"
This question assesses the client's orientation to time, place, and current events. It is useful for assessing cognitive functioning but does not specifically measure insight into one's own mental health.
C. "What do you get when you subtract 7 from 100?"
This question assesses the client's cognitive functioning, specifically mathematical abilities. It is useful for evaluating cognitive skills but does not address insight into mental health.
D. "How do you get money for your needs?"
This question assesses the client's problem-solving abilities and understanding of practical matters. It is relevant for assessing functional abilities but does not specifically measure insight into their mental health condition.
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Related Questions
Correct Answer is D
Explanation
A. "Don't worry about it. Your anxiety will lessen once the massage begins."
This response dismisses the client's concerns and may not be respectful of their boundaries. It does not acknowledge the client's discomfort and does not offer a solution to address their preference.
B. "Why don't you like to be touched by others?"
While the nurse is attempting to understand the client's feelings, this question might come across as invasive or judgmental. The client may not feel comfortable discussing their reasons for not liking to be touched, and this response does not offer an immediate solution to the issue at hand.
C. "I will request that the massage therapist wear gloves during your treatment."
This response shows an attempt to accommodate the client's preference by suggesting a practical solution, such as wearing gloves to create a physical barrier. However, it's important to note that some individuals may still find this uncomfortable, and it might not be a universally effective solution for everyone.
D. "I will tell your provider that you would like a treatment other than massage."
This response acknowledges the client's discomfort and demonstrates respect for their boundaries. It indicates the nurse's intention to advocate for the client's preferences and well-being. By informing the provider about the client's aversion to touch, the nurse opens the door to exploring alternative treatment options that are more suitable for the client's comfort level.
Correct Answer is B
Explanation
A. The client expresses feelings of guilt.
Feelings of guilt are a common part of the grieving process. Many people may experience guilt related to things they said or didn't say, things they did or didn't do before their loved one's death. While it can be challenging, it is not necessarily a maladaptive grief response.
B. The client is unable to perform basic hygiene tasks.
This indicates a maladaptive grief response. If the client's grief has led to such severe impairment in functioning that they cannot maintain basic hygiene, it suggests an inability to cope and function in daily life, which is concerning and requires intervention and support.
C. The client gives away some of the partner's belongings.
This behavior is a common part of the grieving process. It can represent the client's attempt to let go and move on. It might also be an expression of their partner's wishes or a way to help others in need. Giving away belongings is not inherently maladaptive; it depends on the context and the individual's overall coping abilities.
D. The client relocates from a house to an apartment.
Changes in living arrangements after the loss of a loved one are often part of adapting to the new circumstances. It can be a way for the individual to reduce their responsibilities, live in a more manageable space, or seek a fresh start. Relocating, on its own, is not a maladaptive response to grief.
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